Vitamin D and Cancer

In a previous post from January 27, 2016  (http://blog1.smopinions.com/2016/01/7-interesting-facts-about-vitamin-d.html), it was mentioned that there are associations between vitamin D deficiency and certain types of cancer. This post will explain a little bit more about them.

Regarding colorectal cancer, it was noticed about 2 decades ago, that there is more mortality from colorectal cancer in the northern and northeastern parts of the United States, the ones which receive less sunlight. This in itself is not enough to establish a meaningful association, however, it gave a starting point for research. Then, 2 studies showed that having levels above 30 ng/dL in the blood may reduce the incidence of colorectal cancer by half^1,2.

With respect to breast cancer, a recent study found that postmenopausal women may get a benefit from having adequate vitamin D levels in the blood. The risk of developing breast cancer in this particular group of women was lower than in the same group of women with lower vitamin D in their blood³.

Finally, in regards to prostate cancer, it has been found that this cancer is also more common in regions with less sun exposure. In addition, lower vitamin D levels in the blood are related to more aggressive forms of prostate cancer. Last but not least, adequate levels of vitamin D may aid in the slowing of the progression of this type of cancer⁴.

More research is needed in order to confirm and strengthen these associations. In the mean time, it does not hurt to have adequate levels of vitamin D in the blood, particularly for people living north of the 30th parallel.

References

1. Serum 25-hydroxyvitamin D and colon cancer: eight-year prospective study. Garland CF, Comstock GW, Garland FC, Helsing KJ, Shaw EK, Gorham ED. Lancet. 1989;2(8673):1176-8.

2. Meta-analysis: longitudinal studies of serum vitamin D and colorectal cancer risk. Yin L, Grandi N, Raum E, Haug U, Arndt V, Brenner H. Alim Pharm Therap. 2009 30(2):113-25

3. Plasma vitamin D levels, menopause, and risk of breast cancer: dose-response meta-analysis of prospective studies. Bauer SR, Hankinson SE, Bertone-Johnson ER, Ding EL. Medicine (Baltimore). 2013;92(3):123-31

4. Association between serum 25(OH)D and death from prostate cancer. Tretli S, Hernes E, Berg JP, Hestvik UE, Robsahm TE. Br. J. Cancer 2009;100(3):450-4.

Marco A. Ramos MD

Atrial Fibrillation. Will you Ever Have it?

Atrial Fibrillation is one of the most common arrhythmias of the heart. It is often referred as “irregular heart beat” or “quivering of the heart”¹. It is important because it is related to strokes, heart failure and cognitive decline. Its treatment, in addition to trying to control the arrhythmia, usually involves anticoagulation in order to decrease the risk of stroke.

Even if people are healthy and have few or no cardiovascular risk factors, there is a age-related risk of developing atrial fibrillation. This risk has been measured and it increases progressively with age. In one study, people between 55-59 years old have a 0.7% risk, 60-64 years old 1.7%, 65-69 years old 4.0%, 70-74 years old 6.0%, 75-79 years old, 9.0%, 80-84 years old 13.5% and older than 85 years old 17.8%². The risk seems to be slightly higher in men than in women.

The risk of developing atrial fibrillation increases with the presence of conditions such as hypertension, diabetes mellitus, hyperthyroidism, heart failure, obesity, obstructive sleep apnea, excessive sports practice, chronic inflammatory states, and alcohol abuse³. In addition there are genetic markers that might explain why certain people develop atrial fibrillation at a younger age and why white people are more affected than people from African of Hispanic descent. There are mutations in certain genes that increase the risk and there are genetic variants called single nucleotide polymorphisms (SNP) that are associated with early onset atrial fibrillation.

Like with every condition, there are modifiable risk factors and non-modifiable risk factors (like the genetic ones). If anyone has any of the non-modifiable risk factors, it is better to be on the safer side and make sure that more risk is not added to the already present ones. Also, be in close communication with your personal physician for proper prevention and treatment if needed.

References

1. http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/What-is-Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsp#.V3RKAFeL1M8. Obtained June 20, 2016

2. Jan Heeringa, Deirdre A.M. van der Kuip, Albert Hofman, Jan A. Kors, Gerard van Herpen, Bruno H.Ch. Stricker, Theo Stijnen, Gregory Y.H. Lip3, and Jacqueline C.M. Witteman. European Heart Journal. 2006;27: 949-953

Marco A. Ramos MD

Alzheimer's Disease Genetics Explained

Alzheimer’s Disease (AD) is a chronic degenerative disease of the brain which leads to progressive dementia, which is the loss of the mental faculties of a person. Memory, personality, judgement and reasoning can get severely impaired. The development of AD has a strong genetic component, which may be complicated to understand, but I will try to simplify it here.

There is a gene called APOE. This gene encodes a protein called apolipoprotein E. There are 3 variants of the APOE gene (ε2, ε3, ε4). Each of us inherits 2 variants of the gene, so we all are either ε2/ε2, or ε2/ε3, or ε3/ε3, or ε3/ε4 or ε4/ε4 or ε2/ε4. 

The combination ε4/ε4 has the highest possibility of AD. According to one study, at 85 years of age, people with this combination would have a possibility of 51-52% of developing the disease if male, and 60-68% if female. The combination with the lowest possibility is ε2/ε2, it has a 4-5% possibility of AD if male and 6-8% if female. All the other combinations are in between.

It is important to note that this gene is not the only one associated with AD. If you know your particular combination, it is best to consult a healthcare provider for proper advice.

Marco A. Ramos MD

Further reading here:: http://www.ncbi.nlm.nih.gov/pubmed?cmd=Search&term=9343467

Three Reasons for Electing Private Pay Over Insurance for Outpatient Health Care

Being insured in order to to see your primary doctor or specialty physician has become the norm. Many traditional physician practices will only accept you as a patient if you are enrolled in an insurance plan, either government funded or non-government funded. This has created a change in the relationship between a physician and the patients. In this post, I will show three reasons why patients should seek private pay arrangements with the physicians of their choice. 

1. To keep the decision-making between the doctor and the patient. The moment a doctor is allowed by an insurance company to see  patients who pay premiums to it, that doctor is accepting that there is a third entity that will monitor, question and in many changes change the decisions made by the doctor and the patient in the office encounter. 

2. To assure privacy. Once a patient participates in an insurance plan, the patient is surrendering its private health information to a third party. There will be other individuals, employed or contracted by the insurance company, that will review the medical record for different purposes including quality of care, financial analysis and approval or denial of specific treatments.

3. To not be subject to restrictions and limits in insurance plans. Insurance companies can change their plans. Benefits that were part of the plan might not be present in the amended plan. Most of benefits are partially paid and the remainder has to be paid “out-of pocket” by the patient.

The concept of insurance is to spread the risk amongst a pool of people. The greater the pool, the better spread the risk is and the premiums may be lower. This is necessary when we take into account that hospitalizations, surgeries and prolonged treatments like, for example, dialysis or chemotherapy can be extremely costly. However, for outpatient care, when we deal with preventive medicine or with specialist consultations, it would be probably better to seek models that keep the relationship between a doctor and patient strictly between them.

Marco A. Ramos MD

The Importance of Knowing your Disease Process and its Treatment Options

Health issues can be complicated. Not only the diagnoses can be complex and difficult to understand, but the treatment options can also be overwhelming. This is why an encounter with a physician is extremely important. It can have the effect of making the patient understand fully the condition he or she is going through or, it can have the opposite effect if the encounter is too short or the communication skills are just not there.

The first thing that needs to be understood fully by the patient is the disease process that leads to the situation the patient is on. If the case is cancer, renal failure, or heart failure, there is a unique set of circumstances that led to that situation. What needs to be always remembered is that every person is unique. Everyone of us carries a distinct genetic background and have lived different lives with different nutrition and exercise habits. Unless a person is victim of an accident, the causes for any condition are usually multiple. This is  what doctors mean when they use the term “multifactorial”.

In this information era, many people resort to the internet as their source of information. This is the consequence of the internet being readily available, as opposed to a physician, who is usually difficult to find and when found, the encounter might be short and not yielding the expected answers. The internet can be a good source of information, however, there is so much out there that the wrong conclusions can be drawn easily. The other consequence is to make the patient more confused.

The same happens for the treatment options. A long term therapy such as chemotherapy or dialysis should be a process that the doctor and the patient go in (or not go) together, with the doctor providing guidance, not orders. When the patient lacks the right set of information, the decisions made at a given point in time, can lead to expectations that might seem unrealistic in the eyes of the doctor. 

For a patient, knowing the disease process and its treatment options are crucial elements for good healthcare outcomes and a good physician-patient relationship. When the point in which either or these elements are not achieved, a second medical opinion can be what is needed to achieve the elements and ensure good healer outcomes and solidify the relationship between the patient and his or her doctor.

Marco A. Ramos MD

How to Obtain a Second Medical Opinion?

Obtaining a second medical opinion is very important, specially when the medical problem that a person is dealing with is complicated, chronic or needs aggressive and expensive medical care. The primary care provider and the specialist who sees you or your relative may be very good, but ultimately, the body belongs to you and not only you must be seeking  care, but also making sure it is good care.

Here are some steps that may be followed:

1. If you are thinking about obtaining a second medical opinion, you must make up your mind first. If the last medical visit was left with more questions than answers, or you need reassurance, it is always a good habit to give the physician who saw you a call in order to clarify things. Keep in mind that time is not a luxury of doctors these days, so they might just need more time to talk to you. If after talking to the doctor again, questions remain unanswered, then, there is a good case to look for a second opinion.

2. Once the decision is made, you should contact your insurance company in order to see if second medical opinions are covered by your plan and in case they are, to see what physicians can provide it. 

3. When the options are provided, the physicians’ credentials must be verified. You can look into the specific Specialty Board’s website to check the physician’s background and experience.

4. If the choices do not satisfy you, there can be other physicians available. Look into medical schools, hospitals and friends and family recommendations. Do a thorough internet search and verify credentials. Be prepared to pay out of pocket money in these cases.

5. Once the second opinion is obtained, request a written report. This is important because it will give you a document to refer to and will help you when going back to your original physicians. It can contain valuable information and it can help you and your doctor in the developing of the plan of care.

Although requesting a second medical opinion is a right, some physicians may be offended by the fact that you are doing it. Reassure your physician by saying that this is meant for you to be further educated about your condition and its treatment options.

Marco A. Ramos MD

Take a look at www.smopinions.com

The Importance of Individualized Medical Care

In our days, due to the pressures of the health insurance companies (private and public), the legal system, the physician shortage and academia there is a push towards standardizing the medical care at all levels. This would work well if everyone of us were genetically and culturally equal, with the same responses to infectious agents, dietary habits  and the stresses of life in general. However, as you probably already concluded, this is not the case.

Health insurance companies base their profit models in statistics. They use averages, standard deviations and trends in order to make decisions. An individual with a unique problem, who does not fit in the pattern usually creates some degree of stress in the system that needs time to be solved. In many occasions, neither the physician nor the bureaucrats have the time to actually solve the issues.

The legal system uses the “standard of care” as the standard to compare the practicing behaviors of physicians with at the time of malpractice litigation. Because of this, the practicing patterns of physicians tend to be similar regardless of the patients’ uniqueness. This is one of the characteristics of “defensive” medical practice, which increases the cost of care without necessarily increasing its effectiveness.

The physician shortage has created a situation by which physicians do not have enough time to analyze the situation of a particular patient, specially if the problem is complex. This is one of the reasons, why diagnoses of rare conditions can take longer than they would if the physicians had the necessary time to study the rare and complex cases.

Academia has pushed for the practice of “evidence-based medicine”. While this is a great concept specially at the time of gathering knowledge, it can become a problem if the practitioner applies the conclusions of research to patients who do not fit the inclusion criteria of the same research.

There is no simple fix for the healthcare system as a whole. Individuals have to take responsibility of their own healthcare and use the available resources in order to solve their problems, specially if they are complex. for example,there are the private-pay “concierge” practices. These physicians can offer more time to patients and they would definitely make the patient understand his or her own issues. There are also several second medical opinion services, which can provide access to specialists who can dedicate their time to analyze the patient’s case in detail. These services, I believe, understand better the need for individualized medical care.

Marco A. Ramos MD

What I Wish I’d Known About Kidney Stones Before I Had One by Dr. Mary

Have you ever had a kidney stone? I did, in college. Kidney stone pain is very similar to labor, but passing a kidney stone is continuously miserable, whereas the pain of labor comes and goes. Needless to say, I don’t want another one.

With a personal history of kidney stones, I started to get concerned that my morning smoothie might be putting me at risk. Smoothies have a high concentration of oxalates, and about about 80% of kidney stones are made up of calcium oxalate.

Oxalates are naturally present in our bodies. They are also present in varying levels in certain plant foods. Some other symptoms, such as fatigue and vaginal pain, are associated with dietary oxalates, but these associations are unproven. Low-oxalate diets are sometimes recommended to decrease the kidney stone development.

There are only nine foods that are shown to significantly increase urinary concentrations of oxalates:
Parsley
Spinach
Rhubarb
Beets
Nuts
Chocolate
Tea
Wheat bran
Strawberries

This is a big surprise, since many other vegetables are high in oxalates. (Check out the content of your fave veggie here.)

Why do some foods that are high in oxalates not increase the amount of oxalate in the urine?
It’s probably because greens, fruits, and vegetables are very high in calcium, too. Calcium binds the oxalates in the food while it’s still in the intestine, limiting the absorption and allowing the potentially harmful oxalates to be excreted from your precious, beautiful body.

Why do vegetarians have half the risk of kidney stones compared to omnivores?

There are two good reasons for this finding:
1. Meat consumption results in increased acidity in the urine.
The body responds to the increased acidity by adding calcium to the urine, much in the same way my mom takes a Tums when her stomach hurts. The increased calcium in the acidic urine binds the oxalate and whammy! A stone is formed. Keeping the urine alkaline with proteins (from grains and beans) reduces the calcium in the urine and minimizes the risk of calcium-oxalate stones.

2. Collagen in meat supplies the amino acid hydroxyproline, which is metabolized to oxalate.
The daily turnover of collagen from your own body is a major source of hyroxyproline. Just turning over your own collagen accounts for 5 to 20% of the urinary oxalate daily. Dr. John Knight of Wake Forest University School of Medicine in Winston-Salem, N.C. compared oxalate levels in the urine after feeding people diets loaded with gelatin (made from the cow skeleton and loaded with collagen) versus whey, which is a protein by-product of the cheese industry. Those who ate gelatin had much higher levels of urinary oxalate for the next 24 hours.

Just eating 5 to 10 grams of gelatin significantly increased oxalates in the urine for six hours.
How much collagen is in meat? Samples of lean meats contain from 2.5 to 5% collagen by weight and hamburgers are up to 7.1%. Hot dogs and sausages, made from scraps and pieces, are up to 19% collagen by weight. Meat that contains 7% collagen will have 7 grams per serving and 10 grams per about one third of a pound. Meat servings in the range of a hot dog or quarter pounder will increase urinary oxalates for an entire day after consumption.

Several dietary supplements promoted for skin, bone, and joint health also contain gelatin at 10 grams per recommended dose.

What should a person who wants to limit their dietary oxalates do?
Urinary oxalate is predominantly caused by the oxalate created in your own body from collagen breakdown, but it may also be affected by dietary intake of oxalate and calcium.

Although oxalate-rich foods enhanced excretion of urinary oxalate in normal volunteers, the increase was not proportional to the oxalate content of the food. Fruits and veggies that are high in oxalates are often high in calcium too, which prevents the absorption of the oxalate by binding it up in the intestine.

Increased dietary calcium intake may reduce urinary oxalate excretion by binding more oxalate in the gut.

Collagen in meats break down into hydroxyproline, which then breaks down into oxalates. Meat represents a significant source for oxalates in omnivores. One serving of meat increases urinary oxalate levels for 24 hours.

Decreasing meats and processed dairy cuts the risk of kidney stone by 40%. Check out your supplements and reconsider gelatin-containing products. Avoid gelatin-containing foods and desserts.

This first appeared on MindBodyGreen.com

 The article was reproduced with authorization of the author, Dr. Mary Wendt. Click the link for the original article. See Dr. Mary's website at: https://getwaisted.com